november 10 th , 2009 learning from pse study dissemination day
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November 10 th , 2009 Learning from PSE Study Dissemination Day. What kind of PSE learning behaviours are Ontario hospitals engaging in?. Outline. Can we only learn from Catastrophe? Is there variation in learning from PSEs across Ontario hospitals? - PowerPoint PPT PresentationTRANSCRIPT
What kind of PSE learning behaviours are Ontario hospitals engaging in?
November 10th, 2009Learning from PSE Study Dissemination Day
Outline
1. Can we only learn from Catastrophe?
2. Is there variation in learning from PSEs across Ontario hospitals?
3. What learning behaviors do we engage in most often…least often?
4. The case of hospital size
5. Using (and misusing) these data
Learning Behaviours / Responses to PLEs
• Identification & Reporting
• Analysis of Causes
• Change Implementation
• Dissemination / communication
3.383.033.07
2.58
1
2
3
4
Minor Moderate Major NM Major
4-Always
3-Usually
2-Sometim
1-Never
Event learning
n=54
Event learning Event learning Event learning
1.Can we only learn from Catastrophe?Learning Responses to 4 types of PSEs
3.61
2.88
Analysis
Dissem
Matryoshka Dolls Learning from patient safety events takes place in only a very small subset of events
A
1. Safety incidents
2. Recognized safety incidents
3. Recognized and discussed incidents
5. Recognized, and locally investigated
B
C
4. Recognized, discussed and reported:A – in the chartB – to a paper or on-line IR systemC – to person / team with mandate & resources to investigate and make change
2. Is there variation in learning from PSEs across
Ontario hospitals?
Minor event learning scores for 54 Ontario hospitals
Moderate event learning scores for 54 Ontario hospitals
Major NM learning scores for 54 Ontario hospitals
Major event Analysis learning scores for 54 Ontario hospitals
Major event Dissemination learning scores for 54 Ontario hospitals
3. What learning behaviors do we engage in most
often…least often?
% engaging in learning response “always/almost always” OR “usually”
Learning Response Item Minorevent
Modevent
MajorNM
Majorevent
Discussion around these events focuses mainly on system-related factors, rather than focusing on the individual(s) most responsible for the event
87.0 94.4 96.3
Individuals involved in the event contribute to the understanding and analysis of the event
66.7 79.6 85.2 88.9
A multidisciplinary review team in our hospital helps units with the analysis of these kinds of events
83.0 94.4
A formal process for disclosure of events to patients/families is followed and this process includes support mechanisms for patients, family, and care/service providers.
88.5
% engaging in learning response “always/almost always” OR “usually”
Learning Response Item Minorevent
Modevent
MajorNM
Majorevent
We have dedicated “patient safety rounds” where these events are discussed 13.5 28.0
Information about these events is shared with staff informally within the unit (e.g., through personal communica, email, commun books, bulletin boards).
46.3 64.2
Things that are learned from these events are communicated to staff using more than one method (e.g. communication book, in-services, unit rounds, emails) and / or at several times so all staff hear about it
47.2 65.4 62.3
The patient and fam are invited to be directly involved in the processes that follow major events (analyzing what occurred & making necessary changes)
33.3
4. Do PS leadership and hospital size explain variance
in learning from PSEs?
Organizational Leadership for PS and Learning from PSEs
2
2.5
3
3.5
4
2.43 4.93Organizational leadership for patient safety
Learning scores
Major eventanalysis (no effect)
Major eventdissemination
Moderate events
Minor events
Major near misses
Moderate event learning in small and large hospitals under conditions of strong and weak PS leadership
1
1.5
2
2.5
3
3.5
4
low high
Formal organizational leadership for safety
Lear
ning
from
mod
erat
e ev
ents
Small hospital
Large hospital
weak strong
Major event communication in small and large hospitals under conditions of strong and weak PS leadership
1
1.5
2
2.5
3
3.5
4
low high
Formal organizational leadership for safety
Maj
or e
vent
di
ssem
inati
on/c
omm
unic
ation
Small hospital
Large hospital
weak strong
5. Using (and misusing) these data
Challenges of KT– Different purposes/uses for data – Different data for research and QI– Ethics– Timelines
• Grant to results• Staff change: 50% PSO, 46% CEO
… Using (and misusing) these data
• Comparison with peers• Comparison over time• Starting conversations
– Do the PSE learning instrument with the right people: assess current practice
– Take the results (and process?) up and down the organization: goal setting
• Getting CEOs involved through an in-depth PSE case study (Conway, 2008)
• PSE Learning instrument concrete tool to reduce the knowing-doing gap (Pfeffer & Sutton, 2000): action reduces this gap
“In our experience, most boards and leaders overestimate the frontline staff’s ability to improve. In such cases, even with sufficient will and great ideas…execution stalls” (Conway, 2008)
Single-loop learning – quick fixes
Double-loop learning – correcting the underlying causes of a problem